Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a ‘Best Fit’ framework approach

Abstract Background Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision‐making process. We aimed to describe the patient's decision‐making behaviour and shared decision‐making (SDM)‐related barriers and facilitators in breast cancer surgical treatment. Methods We searched eight databases for qualitative studies and mixed‐method studies about breast cancer patients' surgical decision‐making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a ‘best fit framework approach’ to analyze and synthesize the evidence. Results Twenty‐eight qualitative studies and three mixed‐method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision‐making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM. Conclusions Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual‐level and system‐level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice. Patient and Public Contribution This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.


| INTRODUCTION
In recent years, the prevalence and mortality of breast cancer have been increasing. 1 Global Cancer Statistics 2018 estimated that breast cancer accounted for 24.2% of new cancer cases and 15.0% of cancer deaths in women, both ranking first. 1 Breast surgery is the criterion standard of treatment for breast cancer.Common breast cancer surgeries include a mastectomy, modified radical mastectomy (MRM), breast-conserving therapy (BCT), unilateral mastectomy (UM), contralateral prophylactic mastectomy (CPM) and breast reconstruction (BR).The trade-off 2,3 between 'breast preservation' or 'breast removal' and 'reduction of cancer recurrence' or 'quality of life', brought more challenges to patients and their families.Because the breast is a vital organ related to body image and self-esteem for women.When women lose a breast, they may experience psychosocial dysfunction, such as anxiety, stress and an impaired quality of life after treatment. 4For reconstructive surgery, most patients were hesitant between body image, cosmetic results, family finances and the pain of a second operation.Due to the diversity and high sensitivity of the treatment of breast cancer patients, there were difficulties and uncertainties 3,5 in the decision-making process.
Therefore, it is important to understand the patient's wishes and encourage active participation in the decision making process for breast cancer surgery to minimize these negative outcomes.
For decades, the concept of patient participation in medical decision making has attracted wide attention in the healthcare field.Shared decision making (SDM) has been well recognized as an essential element of patient-centred care.Applying SDM could improve patients' knowledge, reduce patients' suffering, actively elicitation of preferences and values and promote patients' involvement and quality of surgical care practice. 6,7Concerns about the appropriateness of SDM may be particularly pronounced in surgical decision making given the often dramatic and irreversible outcomes associated with surgery. 8However, the use of SDM in surgery was still in its infancy, [8][9][10] despite positive feedback from both clinicians and patients. 11e implementation of SDM was influenced by multiple and complex factors, 5,9,10,12,13 such as patient factors, surgeon factors, healthcare organization factors and external environmental factors, especially cultures and local practice patterns.At the same time, the existing studies lack systematic and intrinsic logical correlation of influencing factors, which indicates the need for further analysis based on theoretical frameworks.To our knowledge, some reviews 4,5,13 summarizing the experiences of patients undergoing breast cancer surgery are now available, but there is a lack of comprehensive understanding of the barriers and facilitators associated with SDM, which reveals the lack of attention of most researchers to this important topic.This knowledge gap is a barrier to the provision of effective decision support and patient-centred care by healthcare providers (HCPs).
To fill this gap, this study conducted an integrative review to integrate the relevant qualitative evidence from qualitative studies and mixed-method studies.This study aimed to answer the following questions in breast cancer surgical treatment: (a) What is the patient's decision-making behaviour?(b) What evidence exists regarding the facilitators and barriers related to SDM in clinical practice?

| METHODS
This study combined the qualitative systematic review approach with the 'best fit' framework synthesis (BFFS), which provided a practical and rapid method for qualitative evidence synthesis.This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. 14We have written the research protocol for this systematic review, but not registered or published.

| Literature search
We searched Cochrane Library, Pubmed, Embase, CINHAL, PsycINFO, Chinese Biology Medicine disc, Chinese National Knowledge Infrastructure and Wangfang database for qualitative studies and mixedmethod studies about breast cancer patients' surgical decision making from inception to March 2021.Further searching and supplementing were carried out through the references.Details of the search strategies can be found in Supporting Information S1: Appendix A.

| Data extraction
This systematic review extracted qualitative data from qualitative and mixed studies.Two researchers (H.Z. and L. Y.) independently extracted relevant information from the articles, including population, the interest of phenomenon, context, study design, and so forth.
After data extraction, two researchers cross-checked the extraction results.The data were examined by the third researcher (J.H.) qualified in the health and social sciences to obtain data validation.

| Quality evaluation
The quality of studies was critically appraised by two researchers (H.Z. and L. Y.) independently using the Mixed Methods Appraisal Tool (MMAT) version 2018. 15MMAT was developed for critically appraising different study designs, including qualitative, quantitative and mixedmethod studies.MMAT consists of 5 subscales and 27 items.The first subscale (including entries 1.1-1.5) of MMAT was used to evaluate qualitative studies, and the fifth subscale (Including entries 5.1-5.5) was used to evaluate mixed-method studies.It was advised to provide a more detailed presentation of the ratings of each criterion rather than calculating an overall score.In this study, the number of items with the option of 'yes' in the quality evaluation items was counted.'0' means none of the items were satisfied, and '5' means all of the items were satisfied.In this study, studies with poor study quality will be excluded to reduce the bias of the study results.Any dispute shall be settled by discussion and arbitration by the third researcher (Y.Y.).

| Framework selection
We synthesized the qualitative data based on Andersen's Behavioral Model of Health Services Use 16 and the interprofessional SDM (IP-SDM) model. 17

| BFFS
We followed the BFFS 18 method, proposed by Booth and Carroll.It allowed for both a deductive analysis using an a priori framework and an inductive analysis based on new themes from selected studies that are not part of the a priori framework.The approach therefore was augmentative and deductive (building on this existing model or framework), rather than grounded or inductive (starting with a completely blank sheet).The model identified did not entirely match the topic under study, but it was a 'best fit' and provided a relevant pre-existing framework and themes against which to code the data from the studies identified for this review.Andersen's Model and IP-SDM model provided the a priori framework of themes against which to open code the data extracted from the included studies.The preliminary conceptual framework was extended to generate the final result.Priori framework of themes based on Anderson's Model and IP-SDM model can be found in Table 1.
The results of the literature were integrated using the Nvivo software version 11.Based on understanding the methodology and philosophy of each germplasm research, researchers (H.Z. and L. Y.) constantly read to be familiar with the data, identified the meaningful units of relevant data, open-coded, developed categories and themes and iterative data.Relevant excerpts were coded as new or existing nodes and tree nodes were created from these nodes.
Coding to these nodes continued with the rest of the literature.At the same time, node and tree nodes were created and revised constantly during this process.

| Study selection
A total of 1422 records were retrieved, and these records were imported into the NoteExpress reference management software.
Then 526 duplicates were removed.After preliminary screening of the title and abstract and reading the full text, 31 articles were finally selected (Figure 1).

| Study characteristics
Twenty-eight qualitative studies and three mixed-method studies were included in this study.These included studies were from the T A B L E 1 Priori framework of themes and subthemes.United States, the United Kingdom, China, Canada and other countries.The surgical decision-making situation included a mastectomy, BCT, UM, CPM and BR decision (Table 2).

| Study quality
Fourteen of the 31 reviewed studies were rated as high-quality studies, meeting all the quality criteria (five stars); 16 studies were rated with four stars (Table 3).

| Theme 1: Struggling with various considerations
Concerns about the surgery: The dominant consideration for patients was worrying about cancer recurrence 21,24,27,30,35,37,38,42,46 and taking control of cancer. 27,46Some women felt that the removal of diseased tissue 21,24,35,37,46 could relieve their negative emotion, describing it as eliminating risk, 21,27,30,35 getting rid of it 24,29,35,40,46 and achieving peace of mind. 23,29,35,37Survival was identified as an important issue.Some women thought that UM/MRM would prevent ipsilateral recurrence and CPM would ensure the prevention of contralateral breast cancer. 27,37,48Some patients considered their breasts to be important parts of their body image, and losing them after surgery can have many detrimental effects 21,22,27,29,33,35,[37][38][39][40][41] on physical function and psychological function.Regarding BR surgery, some patients expected it to help them start a new life, 43 while others found it to be a daunting experience. 21,30,34,35Some women have expressed fear of undergoing further surgery 34,42 and the potential risks of the implants used in reconstruction. 34,42nsiderations for follow-up therapy: Some patients considered the impacts of follow-up therapy on their lives, including the risks and side effects of adjuvant chemotherapy, RT, and hormonal therapy. 24,27,30,35,38,44,48Some held firm opinions that choosing BCT would result in struggling with radiation therapy and unwanted side effects, such as nausea and vomiting.
Individual and family considerations: Breasts played an important role in marriage and childrearing as a 'wife' and 'mother'. 34,37,41,43erefore, women had many considerations about the loss of the breast.Intimacy, sexual life, pregnancy, and breastfeeding were some important issues 37,41,44 that patients and their families focused on.Some patients tended to choose the least disruptive choice, 19,21,35,38,41,42 such as choosing a treatment plan with a shorter recovery time or less overall negative effect on their life.
Some patients expressed concern that a prolonged recovery period would impact their ability to care for their young children 40,44 and return to work. 37,38,41,42,44Additionally, for some patients, lack of health insurance or inability to pay for some treatment expenses also affected the choice of therapy. 39,43,45,48
The deliberation process involved rehearsing the risks and benefits and identifying reasons in favour of the decision. 32,37Clinicians typically spend a certain amount of time discussing 21 and consulting 20,27  such as implicit persuasion, may cause decision biases in this process. 36For instance, clinicians stressing or minimizing certain cancer characteristics may influence patients' decision making. 21me women may be hesitant to express their preference and feel unsure about their decision. 22,44Although some patients found the decision-making process challenging, they often felt proud of their achievement upon reflection. 21Failure to fully understand information about risks and benefits, or focusing only on their positive or negative aspects, can lead to difficulties in decision making. 20ilization behaviour of decision support: The decision support included several components, such as family support, 19,[22][23][24]30,[37][38][39]43,46 peer support, 37,38,43 psychological support, 21,23,25,30,33,37 information support, 19,21,24,27,28,30,33,34,37,39,46 and professional support. 32,43Decision support 49 refers to providing decision tools, decision coaching, and clinical counselling to patients to enhance their ability to cope with medical treatment. Clinicalcounselling played a crucial role in resolving treatment problems and contradictions faced by patients. 32,43 However, the brief information provided by cinicians during limited preferences. 36,3825 Some women received detailed information during the consultation, as well as take-home decision aids.24 After introducing the concept and rationale of using SDM early in the consultation, the implementation of SDM was smoother during the doctor-patient interaction process.21,24,36 In general, women who are highly educated, proactive in seeking information, fluent in English, have healthcare knowledge and actively connect with HCPs are empowered to be active decision makers.23,38 Passive decision making still predominates: Some women pointed out that it was their surgeon who made the decision, and their primary responsibility was to understand and comply with their surgeon's recommendation.39,46 Some felt that they lacked choice, even when making preference-sensitive decisions.20,36 Some patients exhibited a set of avoidance strategies that enabled them to avoid making decisions.20,23,24,26,46,47 They adopted passive decisionmaking methods due to some misperception.24,46 Some women thought that 'left the decision to the clinician' meant trusting the clinician. Also,it would not compromise the clinician's expertise and authority and also avoid self-anxiety and worry.24,47 They felt that they were not qualified to ask questions about medical issues because of the lack of professional medical knowledge. 26 Th shock of diagnosis and making decisions in a short time were described by some women as reasons for not engaging further.24 Generally speaking, older women, or those less educated, and less fluent in English, recently immigrated complied more readily with their surgeon's recommendation.

Individual-level factors
Patient factors: In general, well-educated women were more motivated to seek out access to additional support sources, and this appeared to positively influence their SDM experience. 28Patients' decision-making ability was a prerequisite for participation.Language barriers 21,42,48 and having difficulty grasping formal medical information 28,47 were barriers for SDM.And decision-making behaviours were affected by the emotional response 20,[22][23][24]28,30,32,33,[38][39][40][41][45][46][47] like shock and fear. There were misconceptios in the decision-making process.Passive decision making role often seemed from various misperceptions 20,23,24,26,36,38,39,46,47 such as 'left the decision to the doctor' and 'patients were not qualified to ask the question'.It was worth mentioning that some patients had realized the importance of self-participation in the decision making, and they actively communicated with doctors and sought advice from survivors to broaden their information sources.38 Clinician factors: Clinicians' consultation styles varied from open, tailored, two-way dialogues to a more prescriptive style.21 Language varied from everyday to bio-medical.The language and consultation styles adopted by clinicians influenced the accessibility of information to patients. 21 The surgeon's attitude,which was friendly, approachable, and comfortable, can establish trust and great communication effect.29,32 Some patients felt that clinicians were biased 36 in their presentation of options because of the patient's age, race, or socioeconomic status.
Clinician-patient interaction factors: Positively/negatively clinicianpatient interaction quality 21,37 affected the practice of SDM.Misinformation, 23 insufficient support resources 20,34,36,38,42,47,48 and lack of communication 21,26,37,38,45 were barriers for SDM.Also, there was cognitive bias 45 between preoperative information provided by HCPs and comprehended by patients.Also, the quality and quantity of information greatly impacted the patients' behaviour.Access to an abundance of information and supplemental resources was a strong motivating factor for being involved in SDM. 34,36,43Some patients expressed trust in HCPs' recommendations 19,20,23,29,36,37,42,46 and appreciated the effective and helpful communication. 20,24,36,37,42,46However, sometimes this trust was described by some women as enabling them to take a passive role. 24stem-level factors Patients' autonomy and decision rights were primary environmental considerations about implementing SDM.Decision rights 21 were closely related to characteristics of the healthcare setting.At the same time, sufficient time for communication between clinicians and patients could promote the implementation of SDM.However, the lack of time 21 and rushed decision making 28,38,39,43,46 due to the workload were detrimental to the overall quality of medical care. 37It was challenging to accomplish all of this within such a limited surgical consultation time. 9SDM was an effective technique to provide patient-centred care. 36The commonness of diseases and the individuality of patients suggested that HCPs needed to understand the patients' preference. 33Personalized care and continuity of care could better help patients to explain their values 33 and be involved in their disease management. 30,47| DISCUSSION This study finds that paternalistic decision making still occupies a certain proportion, especially among older women or those less educated.Previous systematic review 11 also pointed out that SDM in surgery was still in its infancy, and the use of SDM within the surgical practice was infrequent.Some studies 12,50 found that there were some improper cognitions in the surgical decision-making process, which was similar to our study.It was revealed that some patients avoided participating in treatment decisions on the grounds of doctors' authority and trusting clinicians, 24,47 which was contrary to the idea of SDM. 51As can be seen, these are implicit biases 52 related to medical decision making.According to dual-process theory 53 and Tyler's study, 54 when individuals face time constraints and uncertainty, their decision making may be influenced by heuristics or cognitive shortcuts.Heuristics may lead to bias or cognitive errors.
Under time or other pressures, people are more likely to rely on intuition for decision making.Given the opportunity to deliberate, people 53 are more likely to rely on a rational comparison of risks and benefits.Therefore, SDM still needs to be further promoted 11  This may occur because surgeons sometimes do not have time 9 to discuss these complex trade-offs with patients.Therefore, empowering patients and improving the efficiency of the discussion 9 are important steps to overcome such challenges.This study finds that patients have problems during this process such as limited support approach, insufficient support materials, lack of professional decision support, and so forth.Decision support is both a challenge and an opportunity in the field of healthcare.Therefore, it is particularly important to develop PtDAs 7 and train decision coaches 56 to identify vulnerable groups with deficits in surgical decision making, and improve patients' decision preparation.
This study suggests that there are some barriers and facilitators in the process of shared surgical decision making, including micro (individual) level factors.Our study reports that patients' individual factors such as decision-making ability, emotion, educational level, and decision-making cognition will affect the implementation of SDM.The theory of Planned Behaviour 57 also suggested that behaviours were not only affected by behavioural intention but also restricted by actual control conditions such as personal ability.
Significantly, most patient-related factors are potentially modifiable, and many could be addressed by attitudinal changes at the levels of the patient.Our review also finds some clinicians-related factors such as consultation style and clinician's attitude.There is a general consensus that clinicians-related factors 5 remain the most often cited barrier and facilitators for implementing SDM in clinical practice across many different cultural and organizational contexts.In some cases, this sharing of the decision-making process is not only influenced by the doctor and the patient factor but also clinician-patient interaction factors. 5Covvey et al.'s 50 study also found that in the oncology treatment context, major barriers from the patient perspective included poor clinician-patient communication.
Major facilitators of SDM included physician consideration of patient preferences, positive physician actions/behaviours, and the use of support systems.Annabel's study 5 also demonstrated that the patient-doctor relationship, particularly trust, was identified as a significant factor.This is similar to the results of our study.Trust in the physician or health system has been identified as a key factor not just in patient satisfaction with their care but also in their decision to accept or adhere to treatment at all. 58 this study, it is found that meso-and macrolevel factors such as time, workload, decision-making power, continuity of care and characteristics of the healthcare setting are the main influencing factors for the clinical implementation of SDM.Waddell et al.'s 59 research in the hospital context also found that organization-and system-related factors also included the culture of the organization and leaders engaging in SDM.Also, changing clinical guidelines to promote SDM was reported by clinicians and other stakeholders as being one way in which the system could be changed to facilitate SDM. 59Scholl et al.'s 58 scoping review also found that factors associated with the success of SDM implementation include adequate resourcing, setting of SDM as a priority, integration of SDM into teams and workflow, and cultural and organizational leadership, whereas the system-level factors include clinical guidelines, incentives, education, licensing, culture and policy.This is not reported in this study, which may be due to the small situation focused in this study.

| Study limitations
This study had several limitations.First, although eight databases were searched, it is possible that some eligible studies were missed.
Second, only articles published in English and Chinese were included, and the experiences of participants from other language backgrounds may not be well analyzed.This may have limited the number of articles identified.Third, due to the extensive literature in this research field, we only included qualitative evidence for data synthesis.

| Clinical implications
Inclusion criteria were (a) population: breast cancer patients; (b) interest of phenomenon: surgical decision-making behaviours and SDM behaviours; (c) context: surgical decision including mastectomy, BCT, MRM, UM, CPM and BR and (d) study design: the qualitative study (grounded theory study, phenomenological study, action study and narrative study) and mixed-method study.Exclusion criteria were (a) duplicate publication; (b) unavailable to get the full text; (c) conference abstract and (d) research protocol.

2. 3 |
Literature screening Two researchers (H.Z. and L. Y.) searched the literature independently, and the retrieved literature records were imported into NoteExpress software to remove duplicates.Two researchers independently screened the title and abstract.Articles with unrelated study design, research objectives, participants and context were eliminated.And then, two researchers read the full-text articles to eliminate the inconsistent studies.Any discrepancy was settled by discussion and resolved by a third researcher (Y.Y.).
Andersen's model is widely used to study health service utilization.Clinical SDM is a component of broader health service utilization.The model identifies factors that enable or hinder an individual's access to healthcare services.Key variables in the model include contextual characteristics, individual characteristics, health behaviours and outcomes.This study utilized Andersen's model as a guiding framework to analyze the logical links between influencing factors, decision-making behaviours and decision outcomes.Additionally, due to the specificity of clinical SDM, the IP-SDM model was also employed.The IP-SDM model refines the specific steps of SDM, including (a) patient with a health condition, (b) information exchange, (c) value clarification, (d) feasibility, (e) actual decision making and (f) implementation.This study employed the IP-SDM model to refine these specific behaviours.

Four major themes and 10
subthemes emerged from the selected studies: (a) struggling with various considerations, (b) actual decisionmaking behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM.Table 4 provided details of themes, subthemes, and all codes identified from all included studies.

Figure 2
Figure2showed how these results map onto the 'best fit' framework.As we can see, several changes were made to the prior framework.'Patient with a health condition' was identified as a

23 , 26 3. 2 . 4 |
Theme 4: Multiple facilitators and barriers to SDM Barriers and facilitators influencing SDM included individual-level factors (patient factors, clinician factors and clinician-patient interaction factors) and system-level factors.

Findings from this review
reveal four main themes describing the patient's decision-making behaviour and SDM-related barriers and facilitators.The results of this study suggest that although SDM has occupied a certain proportion, paternalistic decision-making style is still the main decision-making style.There are many barriers and facilitators to the implementation of SDM, such as individual-level and system-level factors.This study helps to discover and overcome unwarranted variations such as information bias and implicit bias, to empower patients to consider treatment choices and integrate patient values and medical evidence to facilitate SDM and improve the quality of care in the clinical practice.
For high-value procedures, patients should demonstrate a full understanding of risks, benefits and alternatives, and there should be concordance between patient preferences and expected behaviours.The study indicates a discrepancy between information exchange behaviours, value clarification, decision support utilization, and SDM due to cognitive and behavioural biases.It is important to avoid cognitive biases that may affect medical decision making.In the future, surgeons should actively interact with their patients and patients should proactively express their personal values and priorities.Additionally, this study provides insight into the barriers and facilitators of SDM in breast cancer surgical treatment.The information gained from this study may be useful in expanding on possible interventions and implications for the global public.Being able to weigh up both barriers and facilitators would aid practical steps in improving SDM for breast cancer surgery.5 | CONCLUSION Surgical decision making was an important step in the patient's medical treatment process, which affected the patient's health outcome and experience.Patients' surgical decision-making styles were various, while paternalistic decision-making style has still occupied a certain proportion.The surgical decisionmaking process was a complex cycle process, with the interweaving and interaction of cognitions and behaviours.When some individuals made decisions, their behaviours were affected by individual-level and system-level factors.Identify the current state of decision-making behaviours and provide targeted professional decision-support tools that can help facilitate the implementation of SDM in clinical practice.Therefore, HCPs and other stakeholders should constantly improve their communication skills and emphasize the importance of decision support to promote the implementation of SDM.
Study quality of the included studies.